> 11) Actions at the sharp end resolve all ambiguity.
> Organizations are ambiguous, often intentionally, about the relationship between
> production targets, efficient use of resources, economy and costs of operations, and
> acceptable risks of low and high consequence accidents. All ambiguity is resolved by
> actions of practitioners at the sharp end of the system. After an accident, practitioner
> actions may be regarded as ‘errors’ or ‘violations’ but these evaluations are heavily
> biased by hindsight and ignore the other driving forces, especially production pressure.
> Organizations are ambiguous, often intentionally, about the relationship between > production targets, efficient use of resources, economy and costs of operations, and > acceptable risks of low and high consequence accidents. All ambiguity is resolved by > actions of practitioners at the sharp end of the system. After an accident, practitioner > actions may be regarded as ‘errors’ or ‘violations’ but these evaluations are heavily > biased by hindsight and ignore the other driving forces, especially production pressure.